Patient Portal Sign-up Information:

Use this form to request a CMH Patient Portal account. Once you have been registered for the CMH Patient Portal, you will receive an email from mychart@citizensmemorial.com with instructions to complete your registration.

HOTMAIL USERS PLEASE NOTE: Please go to your Hotmail email account and add mychart@citizensmemorial.com to your contacts. Hotmail will not accept an email from our address unless you add it as a contact.

Proxy access may be requested in person at any CMH facility or by telephone at (417) 328-6304. The patient granting proxy access to their account must verify the request.

Name

Social Security Number

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Address

City

State

Zip

Phone

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Date of Birth

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Email Address

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Clinic Account Number or Medical Record Number

How did you find out about the CMH Patient Portal?

Other:

Today's Date

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This form will be securely routed to CMH. You may be contacted by a CMH Representative to confirm your identity and that you requested access to your medical record via the CMH Patient Portal.